Cost-Effectiveness Analysis of Diagnosis of Duchenne/Becker Muscular Dystrophy in Colombia.

OBJECTIVES: To determine the cost-effectiveness ratio of different courses of action for the diagnosis of Duchenne or Becker muscular dystrophy in Colombia. METHODS: The cost-effectiveness analysis was performed from the Colombian health system perspective. Decision trees were constructed, and different courses of action were compared considering the following tests: immunohistochemistry (IHC), Western blot (WB), multiplex polymerase chain reaction, multiplex ligation-dependent probe amplification (MLPA), and the complete sequencing of the dystrophin gene. The time horizon matched the duration of sample extraction and analysis. Transition probabilities were obtained from a systematic review. Costs were constructed with a type-case methodology using the consensus of experts and the valuation of resources from consulting laboratories and the 2001 Social Security Institute cost manual. Deterministic sensitivity and scenario analyses were performed with one or more unavailable alternatives. Costs were converted from Colombian pesos to US dollars using the 2014 exchange rate. RESULTS: In the base case, WB was the dominant strategy, with a cost of US $419.07 and a sensitivity of 100%. This approach remains the dominant strategy down to a 98.2% sensitivity and while costs do not exceed US $837.38. If WB was not available, IHC had the best cost-effectiveness ratio, followed by MLPA and sequencing. CONCLUSIONS: WB is a cost-effective alternative for the diagnosis of patients suspected of having Duchenne or Becker muscular dystrophy in the Colombian health system. The IHC test is rated as the second-best detection method. If these tests are not available, MLPA followed by sequencing would be the most cost-effective alternative.

Understanding community-based rehabilitation and the role of physical and rehabilitation medicine.

Community-based rehabilitation (CBR) is an accepted model to improve the delivery of rehabilitation in the community. It includes the access to health care, education, labor and accessible environments. The role of Specialists in Physical and Rehabilitation Medicine in this strategy (SPRM) is not very well defined. On the occasion of the international consultation for the WHO Action Plan for persons with disabilities, a discussion about the meaning of CBR and the role of SPRM on CBR has occurred among the International Society of Physical and Rehabilitation Medicine (ISPRM) members. The following major questions were identified; what is CBR? What is the role of Specialists in Physical and Rehabilitation Medicine (SPMR) in CBR? A review of the literature and a discussion among experts was held to answer these questions. It is of major importance to distinguish between the two concepts of CBR: The first one is the policy or management strategy of CBR that was developed by WHO about 30 years ago. The second one is the provision of basic rehabilitation services offered at the community level. CBR strategy must also addresses the need for optimal access to specialized rehabilitation services and will have a key role in the design and building of so-called "Basic Rehabilitation Services." The authors proposed a scheme, which integrates all relevant aspects surrounding the concept of CBR; levels of care rehabilitation services and the roles proposed for SPRM. In addition, the convention for the rights of persons with disabilities and the conceptual framework of the ICF was taken into account.

Ensayo clínico aleatorizado con grupos paralelos para comparar los cambios en los niveles del pro-péptido natriurético cerebral (Pro-PNC 1-76 ) en pacientes con falla cardiaca crónica sometidos a un programa de ejercicio supervisado versus basado en la comunidad / Randomized clinical trial with parallel groups to compare changes in N-terminal prohormone of brain natriuretic peptide (ProBNP1-76) levels in patients with chronic heart failure subject to a supervised exercise program versus a community based exercise program

Resumen Objetivo: evaluar los niveles de pro-péptido natriurético cerebral (Pro-PNC - 76) de un grupo de pacientes con falla cardiaca crónica, quienes realizaron un programa de ejercicio protocolizado y compararlos con un grupo control con ejercicio basado en la comunidad. Diseño y métodos: ensayo clínico controlado con: doble enmascaramiento, diseño paralelo en pacientes mayores de 18 años, diagnóstico de falla cardiaca clasificación New York Heart Association (NYHA) II-IV para comparar el cambio en los niveles de pro-péptido natriurético cerebral (Pro-PNQ 1-76 ). Resultados: veintitrés pacientes ingresaron al grupo de intervención y 26 al grupo control. Fallecieron cinco pacientes, seis se rehusaron completar todas las evaluaciones y un paciente no logró realizar la prueba de esfuerzo cardiopulmonar. Los niveles de pro-péptido natriurético cerebral (Pro-PNC1-76) y el consumo de oxígeno (VO2) no se modificaron en el grupo de intervención de forma estadísticamente significativa al compararlo con el grupo control. La calidad de vida relacionada con la salud mejoró significativamente en el grupo de intervención en las dimensiones de cambio en la percepción del estado de salud (p=0.007), desempeño emocional (p=0.011), desempeño físico (p=0.006), función física (p=0.024), salud mental (p=0.009) y salud general (p=0.01). Conclusión: la aplicación de un programa de ejercicio supervisado en pacientes con falla cardiaca no modificó los niveles de péptido natriurético cerebral, ni el consumo de oxígeno a las ocho semanas, pero fue efectivo para mejorar la calidad de vida relacionada con la salud (Clinical trials número NCT02087670). (Acta Med Colomb 2017: 42: 180-188).

Abstract Objective: To evaluate ProBNP 1-76 levels of a group of patients with chronic heart failure, who performed a protocolized exercise program and compare them with a control group with community-based exercise program. Design and Methods: Controlled clinical trial with double masking, parallel design in patients older than 18 years with diagnosis of heart failure, New York Heart Association (NYHA) II-IV Classification, to compare the change in Pro-Brain Natriuretic Peptide (ProBNP 1-76 ) Results: Twenty-three (23) patients were admitted to the intervention group and 26 to the control group. Five patients died, six refused to complete all assessments and one patient failed to perform the cardiopulmonary exercise test. ProBNP1-76 levels and oxygen consumption (VO2) were not altered significantly in the intervention group when compared to the control group. Health-related quality of life improved significantly in the intervention group in the dimensions of change in the perception of health status (p = 0.007), emotional performance (p = 0.011), physical performance (p = 0.006), physical function (p = 0.024), mental health (p = 0.009) and general health (p = 0.01). Conclusion: The application of a supervised exercise program in patients with heart failure did not modify brain natriuretic peptide levels or oxygen consumption at eight weeks, but was effective in improving health-related quality of life (Clinical trials number NCT02087670). (Acta Med Colomb 2017: 42: 180-188).

Cost-Utility Analysis of Reconstruction Compared With Primary Amputation for Patients With Severe Lower Limb Trauma in Colombia.

BACKGROUND: To establish, from the health system perspective, the cost-utility relationship of limb reconstruction compared with primary amputation for patients older than 32 years with grade IIIB and IIIC severe lower limb trauma in Colombia, S.A. METHODS: A Markov model was built including different short-term and long-term states that represent the main events that a patient could experience after a lower limb amputation or a reconstruction. A 42-year time horizon was considered for the base case. Transition probabilities were obtained from a systematic review of the clinical literature. The health outcome selected was the quality-adjusted life years. Costs were determined by expert consensus using the standard case methodology, and valuation of resources was conducted with national-level pricing manuals. Deterministic sensitivity, scenarios, and probabilistic analyses were conducted. RESULTS: In the base case, the reconstruction of the limb compared with primary amputation was a dominant strategy; that is, reconstruction provides more quality-adjusted life years at a lower cost. This result changed only when the time horizon was less than 6 years or when the probability of a secondary amputation was >65%. CONCLUSIONS: Limb reconstruction is a dominant strategy compared with primary amputation, which is a conclusion that holds in most scenarios this study examined. Therefore, it should be considered in patients who, according to the clinical criteria and the severity and characteristics of their trauma, can benefit from this technique. LEVEL OF EVIDENCE: Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of early treatment with carbamazepine in prevention of neuropathic pain in patients with spinal cord injury.

OBJECTIVE: The aim of this study was to evaluate whether early treatment with carbamazepine decreases the incidence of neuropathic pain (NP) or its intensity in patients with spinal cord injury. DESIGN: This study was a randomized, double-blind, placebo-controlled clinical trial at a third-level university hospital involving patients older than 18 yrs with a diagnosis of spinal cord injury sustained within 2 wks before enrollment and without evidence of NP. The patients received either carbamazepine up to 600 mg/day or placebo for 1 mo. Pain intensity was measured with a 10-cm visual analog scale and the SF-36 bodily pain subscale; quality-of-life, with the Short Form 36 (SF-36) Scale; and depression, with the Zung Self-Rating Depression Scale. Measurements were carried out at the start of the randomized trial and at the 1-, 3-, and 6-month follow-up assessments. RESULTS: Twenty-one of 46 patients developed NP. At the 1-, 3-, and 6-month follow-up assessments, NP was present in 4, 11, and 10 patients of the carbamazepine group and in 8, 9, and 8 patients of the placebo group, respectively. At 1 mo, two patients in the carbamazepine group vs. eight patients in the placebo group reported moderate/intense pain (visual analog scale, ≥4.0; P = 0.024). At the 3- and 6-month follow-up appointments, moderate/intense pain was reported by eight vs. six (P = 0.498) and six vs. eight patients (P = 0.298), carbamazepine and placebo group, respectively. There was no difference in the depression ratings or in any of the SF-36 scales. CONCLUSIONS: Early intervention with carbamazepine decreased NP incidence at the 1-month but not at the 3- and 6-month follow-ups in the group of patients with acquired spinal cord injury.

Estudio descriptivo del programa de rehabilitación cardiaca de la Clínica Las Américas / Descriptive study of the cardiac rehabilitation program of the Clínica Las Américas

Estudio descriptivo de antes y después que demuestra la eficacia y seguridad del Programa de Rehabilitación Cardiaca de la Clínica Las Américas, con base en un seguimiento a 77 pacientes, en el que se evidenció mejoría de la capacidad funcional así como disminución del perímetro abdominal y de las cifras basales de presión arterial sistólica y diastólica sin complicaciones severas, en todos los tipos de paciente, independientemente de la fracción de eyección o las variables demográficas. De igual forma, se describen las características epidemiológicas de la población y de los factores de riesgo cardio-cerebro-vascular.

A before and after descriptive study that shows the efficacy and safety of the Cardiac Rehabilitation Program of the Clínica Las Americas, based on the follow-up of 77 patients in which we evidenced improvement in functional capacity as well as a decrease of abdominal girth and baseline values of systolic and diastolic blood pressure without severe complications in all type of patients, regardless of ejection fraction or demographic variables. Likewise, we describe the epidemiological characteristics of the population and the cardio-cerebro-vascular risk factors.